Borgess Medical Center
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2 Quality Report Borgess Medical Center HCO ID: Gull Road ( w w w.borgess.com Summary of Quality Information Accreditation Programs View Accreditation History Hospital Accreditation Decision Accredited Effective Date 6/25/2016 Last Full Survey Date 6/24/2016 Last On-Site Survey Date 6/24/2016 Advanced Certification Programs View Certification History Heart Failure Certification Decision Certification Effective Date 11/11/2016 Last Full Survey Date 11/10/2016 Last On-Site Survey Date 11/10/2016 Primary Stroke Center Certification Decision Certification Effective Date 11/10/2016 Last Full Survey Date 11/9/2016 Last On-Site Survey Date 11/9/2016 Sites
3 Allegan Specialty Clinic 570 Linn Suite 570 Allegan, MI, Borgess Anticoagulation & Device Clinic DBA: Borgess Anticoagulation & Device Clinic 1722 Shaffer Street, 3rd floor Borgess at Woodbridge Hill Radiology 7901 Angling Road Portage, MI, Borgess at Woodbridge Hills Laboratory 7901 Angling Road Portage, MI, Laboratory Draw Station (Outpatient Borgess Behavioral Health Richland 8450 North 32nd St Richland, MI, Behavioral Health (Non 24 Hour Care - Adult Behavioral Health (Non 24 Hour Care - Child/Youth Borgess Cardio Thoracic Surgery 1711 Shaffer St Borgess Cardiology Group 1717 Shaffer Street Borgess Bariatric Center Borgess Internal Medicine
4 Borgess Surgical Specialties Borgess Cardiology Group S M43 Highway, Suite 2 Delton, MI, Borgess Family Medicine Borgess Orthopedics Borgess Cardiology Group - Health Park 3035 Capital Ave Battle Creek, MI, Borgess Cardiopulmonary Rehabilitation 3025 Gull Road Borgess Cardiothoracic Surgery 3035 Capital Ave SW Borgess CorpFit Battle Creek 842 E. Columbia Ave Borgess CorpFit Occupational Health Clinic 1521 Gull Rd, Suite 430 Borgess Diabetes & Endocrine Center 1722 Shaffer Street, 3rd floor
5 Borgess Family and Internal Medicine 3035 Capital Ave SW Borgess Cardiology Group Borgess Cardiothoracic Surgery Borgess Diabetes Borgess Health Park Laboratory Borgess Health Park PT/OT Borgess Health Park Radiology Borgess Orthopedics Borgess Pulmonary and Sleep Lab Borgess Surgical Specialties Borgess Women's Health Neurosurgery of Kalamazoo Borgess Family and Internal Medicine 940 John St. Kalamazoo, MI, Borgess Family Medicine 9880 E. Michigan Ave. Suite 100 Galesburg, MI, Borgess Family Medicine Red Arrow Highway Mattawan, MI, Borgess Heart Center For Excellence Borgess Family Medicine - Delton S. M-43 Highway Delton, MI, Borgess Family Medicine and Pediatrics 345 Naomi St
6 Plainwell, MI, Borgess FireKeepers Michigan Ave Battle Creek, MI, Borgess Geriatric Assessment Center 1541 Gull Road, Suite 100 Borgess Health Park DBA: Borgess Health Park - PT/OT/Speech 3035 Capital Ave SW Borgess Health Park Laboratory 3035 Capital Ave SW Laboratory Draw Station (Outpatient Borgess Health Park Radiology 3035 Capital Ave SW Borgess Heart Center - Coldwater 360 E. Chicago St. Coldwater, MI, Borgess Heart Center - Marshall 215 E. Mansion, Ste 38 Marshall, MI, Borgess Heart Center for
7 Excellence 1722 Shaffer Street Borgess Cardiology Group Borgess Cardiothoracic Surgery Borgess Diabetes Heart Failure Clinic Borgess Heart Center of Excellence Red Arrow Hwy Mattawan, MI, Borgess Internal Medicine 842 E. Columbia Avenue Battle Creek, MI, Borgess Pulmonary Medicine Columbia Borgess Internal Medicine 1717 Shaffer, Suite 108 Borgess Internal Medicine Woodbridge HIlls 7775 Angling Road Portage, MI, Borgess Medical Center DBA: Borgess Medical Center 1521 Gull Road Behavioral Health (Day Programs - Child/Youth Behavioral Health (Non 24 Hour Care - Adult Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult Behavioral Health (24-hour Acute Care/Crisis Stabilization - Child/Youth Behavioral Health (Partial - Borgess Heart Failure Cl O/R
8 Child/Youth Cardiac Catheterization Lab (Surgical Services Cardiac Surgery (Surgical Services Cardiothoracic Surgery (Surgical Services Cardiovascular Unit (Inpatient CT Scanner (Imaging/Diagnostic Services Dialysis Unit (Inpatient Ear/Nose/Throat Surgery (Surgical Services EEG/EKG/EMG Lab (Imaging/Diagnostic Services Gastroenterology (Surgical Services GI or Endoscopy Lab (Imaging/Diagnostic Services Gynecological Surgery (Surgical Services Gynecology (Inpatient Inpatient Unit (Inpatient Interventional Radiology (Imaging/Diagnostic Services Labor & Delivery (Inpatient Magnetic Resonance Imaging (Imaging/Diagnostic Services Medical /Surgical Unit (Inpatient Medical ICU (Intensive Care Unit Neuro/Spine ICU (Intensive Care Unit Neurosurgery (Surgical Services Normal Newborn Nursery (Inpatient Nuclear Medicine (Imaging/Diagnostic Services Ophthalmology (Surgical Services Orthopedic Surgery (Surgical Services Peer Support (Non 24 Hour Care Plastic Surgery (Surgical Services Post Anesthesia Care Unit (PACU (Inpatient Radiation Oncology (Imaging/Diagnostic Services
9 Rehabilitation Unit (Inpatient Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization Sleep Laboratory (Sleep Laboratory Surgical ICU (Intensive Care Unit Surgical Unit (Inpatient Thoracic Surgery (Surgical Services Ultrasound (Imaging/Diagnostic Services Urology (Surgical Services Vascular Surgery (Surgical Services Certification Programs Heart Failure Primary Stroke Center Borgess Medical Commons S. M-43 Delton, MI, Borgess Neurology 1541 Gull Road, Suite Borgess Geriatric Assessment Center Neurosurgery of Kalamazoo NIS at Borgess Borgess Neurology 215 Mansion, Suite 1H Marshall, MI, Borgess Neurology of Battle Creek 2845 Capital SW, Suite 201
10 Borgess Orthopedics 2490 S. 11th Street Kalamazoo, MI, Borgess Rhematology Borgess ProMed Pediatrics Mattawan Red Arrow Highway Mattawan, MI, Borgess ProMed Pediatrics Woodbridge 8001 Angling Road Portage, MI, Borgess PT/OT 2490 S. 11th Street Kalamazoo, MI, Borgess Pulmonary Medicine 1535 Gull Road, Ste. 130 Borgess Surgical Specialties Colorectal Surgery Borgess Surgical Specialties Trauma Surgery Borgess Women's Health Borgess Pulmonary Medicine Sleep Lab 8001 Angling Road Portage, MI, Borgess Pulmonary& Sleep Medicine 3035 Capital Ave SW
11 Borgess Rheumatology 2889 S. 11th Street Kalamazoo, MI, Borgess Spine 3025 Gull Road Perform Invasive Procedure Borgess Spine Physical Therapy 3025 Gull Road Borgess Surgical Specialities 1717 Shaffer, Suite 124 Borgess Surgical Specialities - Bariatrics Borgess Surgical Specialities - General; Surgery Borgess Surgical Specialities - Westside 6565 West Main Kalamazoo, MI, Anesthesia Borgess Westside Radiology 6565 W. Main Street Kalamazoo, MI, Borgess Women's Health DBA: Borgess Women's Health - Plainwell 671 Allegan Street Plainwell, MI, Perform Invasive Procedure
12 Borgess Women's Health - Battle Creek 3035 Capital Ave SW Perform Invasive Procedure Borgess Women's Health - Currier Drive 7895 Currier Drive Portage, MI, Perform Invasive Procedure Borgess Women's Health - MSB 1535 Gull Rd Suite 250 Perform Invasive Procedure Borgess Woodbridge Occupational Health 7901 Angling Rd, Lower Level Portage, MI, Borgess Wound and Hyperbaric Center 1717 Shafer Rd, Suite 202 Perform Invasive Procedure Currier Drive Lab 7895 Currier Drive Portage, MI, Laboratory Draw Station (Outpatient Delano Clinic 7895 Currier Drive Portage, MI, Behavioral Health (Non 24 Hour Care - Adult
13 Behavioral Health (Non 24 Hour Care - Child/Youth Heart Failure Clinic 1722 Shaffer St, Suite 3 Immediate Medical Care 7901 Angling Road Portage, MI, Urgent Care Neurosurgery of Kalamazoo 6565 West Main Kalamazoo, MI, Borgess Surgical Specialties Neurosurgery of Kalamazoo 1541 Gull Road, Suite 200 Neurosurgery of Kalamazoo 215 E. Mansion St, Suite 3B Marshall, MI, Orthopedics Walk-in Clinic 1701 Schafer Oshtemo Physical Therapy 2490 South 11th Street Kalamazoo, MI, ProMed Family Medicine 7901 Angling Road
14 Portage, MI, Diagnostic & Lab Services Immediate Medical Care Physical & Occupational Therapy Woodbridge Pharmacy ProMed Family Medicine 1241 W. Broadway Three Rivers, MI, ProMed Family Medicine and Pediatrics 8450 N. 32nd Street Richland, MI, Three Rivers Specialty Clinic 711 S. Health Parkway, Medical Office Building 1 Three Rivers, MI, Westside Laboratory 6565 W. Main Street, Suite 110 Kalamazoo, MI, Laboratory Draw Station (Outpatient Woodbridge PT and OT 8001 Angling Rd Portage, MI, Laboratory Draw Station (Outpatient
15 Special Quality Awards Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice of updating Special Quality Awards until further notice 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2013 Gold Plus Get With The Guidelines - Heart Failure 2012 Silver - The Medal of Honor for Organ Donation 2010 Silver - The Medal of Honor for Organ Donation National Patient Safety Goals and National Quality Improvement Goals Show Keys + Symbol Key This organization achieved the best possible results This organization's performance is above the target range/value This organization's performance is similar to the target range/value This organization's performance is below the target range/value This measure is not applicable for this organization Not displayed Measures Footnote Key The measure or measure set was not reported. The measure set does not have an overall result. The number is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The measure results are not statistically valid. The measure results are based on a sample of patients. The number of months with measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement. There were no eligible patients that met the denominator criteria. The Joint Commission only reports measures endorsed by the National Quality Forum. * This information can also be viewed at Hospital Compare. ** Indicates per 1000 hours of patient care.
16 *** The measure was not in effect for this quarter Null value or data not displayed. Disease-Specific Care Certification 2008 National Patient Safety Goals Nationwide Comparison: Statewide Comparison: Hospital 2016 National Patient Safety Goals Nationwide Comparison: Statewide Comparison: Reporting Period: July June 2016 National Quality Improvement Goals: Emergency Department National Comparison: 2 Statewide Comparison: 2 Hospital-Based Inpatient Psychiatric Services National Comparison: 2 Statewide Comparison: 2 Immunization National Comparison: 2 Statewide Comparison: 2 Perinatal Care National Comparison: 2 Statewide Comparison: 2 Stroke Care National Comparison: 2 Statewide Comparison: 2 Venous Thromboembolism (VTE National Comparison: 2 Statewide Comparison: 2 New Changes to Quarterly Measure Download Quarterly Measure Results The Joint Commission only reports measures endorsed by the National Quality Forum. * State results are not calculated for the National Patient Safety Goals.
17 National Quality Improvement Goals: Borgess Medical Center HCO ID: Gull Road Kalamazoo, MI, Error
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